Sunday, August 9, 2009

American Values and Health Reform (1): Responsibility

This spring the Hastings Center published eleven short essays as a small booklet – “Connecting American Values with Health Reform.” The aim of the project was to go beyond the dizzying area of sound bites and legislation in progress to consider what we want health reform to accomplish and what values our institutions and practices should be built upon. In my view the publication (which I contributed to) can be useful to the health reform process. This post is the first of three I’ll do based on the Hastings Center project.

My assignment was to discuss how the value of “responsibility” relates to the health reform debate. As I sat down to write the piece my mind drifted to a movie I hadn’t seen for at least twenty years – “Shane.” I got a copy from the local library and brought it to my office, hoping colleagues and students wouldn’t discover me watching a cowboy film.

My association to “Shane” was on target. In the film little Joey Starrett is torn between two icons of responsibility – his father, Joe, the homesteader, and Shane, the mysterious cowboy gunslinger.

Joe and Shane embody the two poles of responsibility in U.S. moral discourse. Joe exemplifies responsibility as social solidarity – building a caring community that takes responsibility for the welfare of its members. For homesteaders like Joe, the emblem of responsibility is barn-raising, in which the community bands together to help individuals meet a basic need. Shane exemplifies responsibility as individual action. For cowboys like Shane, the emblem of responsibility is the six-gun and the knowledge of when and how to use it.

Our love affair with the myth of the heroic cowboy enhances the attractiveness of market-based health reform proposals. In place of the cowboy these proposals envision a heroically empowered “consumer,” motivated by “skin in the game” and armed with knowledge, who strides into the marketplace to make choices of high-quality, low-cost health care, in accord with their own values. The empowered consumer stands tall and takes orders from no one. This constellation of values is being used to whip up the frenzy of disruptions we’re currently seeing in town hall meetings around the country. The would-be Shanes shouting at their representatives and even threatening death represent the value of individual responsibility run amok.

Proposals that emphasize universal coverage – like the single payer plan and variants of the Massachusetts program – are enhanced by the myth of an Edenic, barn-raising frontier. The single payer plan envisions a society that pools its resources to minister to the health needs of each member of the community. The Massachusetts plan plays down the communitarian ethos of the single payer approach by (1) requiring each individual to buy insurance rather than requiring contribution via taxes and (2) gives the individual a range of insurance choices. (see here, here and here for discussions of the Massachusetts program.)

One reason the Massachusetts plan has attracted so much attention nationally is the way it addresses the deeply rooted American standoff between the proponents of individual responsibility (Shane) and societal responsibility (Joe Starett). The architects of the plan like to point out that it requires everyone to take responsibility. Individuals are required to purchase health insurance, but are free to choose among a large number of private ("nongovernmental") plans. Employers are required to contribute. The state is required to pay for those too poor to buy their own insurance. And if the state's recent recommendation goes through, providers will be required to form "accountable organizations" and work within budgets.

In his inauguration speech, President Obama invoked responsibility as a major theme - "What is required of us now is a new era of responsibility - a recognition, on the part of every American, that we have duties to ourselves, our nation and the world." It sounds as if the President wants to side with both Shane and Joe Starrett. Whatever emerges from the national health reform process will almost certainly have to find ways of integrating the virtues of Shane and Joe!